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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1s4/cJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application "is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rales and Regulations of the San Joaquin Local Health District. <br /> '�'�77���01ive _ <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> t Owner's Name Greg Lewis . - Phone 599- 15 <br /> Address �� "- ? G- <br /> i city <br /> Contractor's Name HENNINGS BROS. DRILLING CO. " INC'. ` F <br /> 2501) License X90^$ Phone 522-1031. <br /> est um e. o es o., a 95350 .. <br /> TYPE OF WORK (Check) : NEW WELL "/ DEEPEN/? RECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / PUMP REPAIR -/-7—PUMP REPLACEMENT f <br /> I Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL�� i <br /> INTENDED TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industriall =Q 'Cable Tool Dia. of Well Excavation <br /> X <br /> Domestic/private Drilled <br /> _ Domestic Dia, of Well Casing <br /> /public <br /> Driven <br /> IrrGauge of Casing <br /> igation _ Gravel Pack [n <br /> Cathodic Protection Rotar Depth of Grout Seal -�. L <br /> Disposal —'"� y Type of Grout , i'1M`. <br /> ,� Other Other Information <br /> Geophysical "'---�-�--- --• <br /> Surface Seal InstalledBy:' <br /> zy <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P . <br /> PUMP REPLACEMENT /% State Work Done <br />_.PUMP REPAIR: State <br /> "Work Done <br /> DESTRUCTION OF WELL: Well Diameter,i ! <br /> Describe Materia: and procedure Approximate Depth I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District, <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN 'DAYS <br /> after completion of my work .on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.... The above <br /> information is true to the-best,of my.-knowledge and belief. I WILL CALL FORA 'GROUT INSPECTION.- <br /> PRIOR TO GROUTI VI INSPECTION. <br /> SIGNED TITLE f <br /> RE E ! <br /> PHASE I R DEPARTMENT US NLY <br /> APPLICATION" ACCEPTED BY-Li[/ ` 4 <br /> ADDITIONAL COMMENTS: DATE /c7-2`1-� I <br /> PHASE I G OUT INSPECTION4 SE NAL INSPECT N <br /> INSPECTION BY DATE 7-2. INSPECTION DATE <br /> E H 1426 <br /> Rev. 1.--74 r <br />